The making of a new facility.
It happens sooner or later - the combination of an aging and overcrowded facility, a booming geriatric population, and residents needing increasingly intensive health care forces nursing home owners to make a decision: What should they do to bring the nursing home up-to-date? That decision was especially pressing for the owners of Cleveland's historic Montefiore Home. Reviewing the evolution of the building constructed in 1919, and the many modifications made to it since, they decided that the time had come to plan a state-of-the-art facilty that would accommodate the community's needs for years to come. After years of grass roots-level planning and fund-raising, and a year-and-a-half of construction, the inviting-looking 3-story, 175,000 square-foot structure opened its doors. If its appearance was impressive, so was the fact that, in today's world of construction projects, no one ended up threatening to sue anyone. Quite the contrary, mutual pride seemed to be the order of the day.
What were the ingredients of this "happy ending"? And how might other nursing home managements, whether building new or renovating, get into the act of successful planning and construction? Recently the people at the heart of the Montefiore project - administrator Edward Vinocur, architect Brad Perkins and building committee chairman Darrell Young - recounted the story in a conference call with NURSING HOMES Editor Richard L. Peck.
Once you had decided to build a new facility, how did you determine what sort of facility you needed and wanted?
Vinocur: We conducted many, many meetings with community groups asking them to prioritize what they wanted in a new facility. Among the top-ranked requests were: all-private rooms, 4 number of relatively intimate common areas allowing family and residents to sit and visit, and space for community activities and religious observance.
Perkins: I recall, too, that they wanted decentralized dining facilities and special nursing units for small groups of people; they wanted facilities for Alzheimer's disease and hospice, for example.
Vinocur: After we learned what the community wanted, we then had to decide how much we could afford to spend - how much money we could raise in the community, how much debt service we could afford, and what sort of limitations would be placed on our expenditures by Ohio's Certificate of Need.
Once You arrived at your basic goals, how did you go about selecting an architect to help realize them?
Young: I think our building committee received responses to our "requests for proposals" from approximately 87 architectural firms. These we rather rapidly narrowed down to eight whom we interviewed, the whole process taking about a year. Our selection criteria were background and experience with nursing homes and housing for the aged, cost, knowledge of the community and socialization skills.
Perkins: A high premium was placed on personal chemistry, on being able to work together, because designing and building a large, complex new facility requires a long, close working relationship.
Young: Our basic concept was that we wanted a world-class facility and a firm with the skills, experience and depth to deliver that type of facility. Maintaining that goal helped us narrow down the field and finally select Brad's firm.
When you reached the architectural planning stage, what were some key considerations?
Perkins: There were several factors we had to keep in mind - the budget available (within the limits approved by CON), the square footage (the total approved by the state), meeting some very difficult site challenges....
Young: Our site was set back from the highway, behind a neighboring nursing facility, Menorah Park, and we had to reconstruct a long entrance way, reconfigure Menorah Park's Parking lot, and in general work on some 40 acres to develop our 10-acre site.
Perkins: Then, of course, we had to deal with building code constraints. These are typically very rigid throughout the United States. Ohio is more flexible than most, but most states simply don't recognize the varying needs of different patient populations - the chronically dependent vs. those who are relatively more ambulatory vs. those who need specialized care, such as those suffering from Alzheimer's.
Ed Vinocur and the trustees wanted state-of-the-art Alzheimer's care. That meant breaking down the typical 40- to 50-bed nursing care unit into smaller sub-groups, because grouping that many Alzheimer's patients can cause considerable agitation. We worked, too, to develop smaller units for dining, activities, socializing - in general, a more sensitive, private setting. Fortunately, the combination of Montefiore's reputation and Ohio's willingness to be flexible helped a great deal. In most states, this sort of thing is a very tough sell.
Young: Knowledge of the codes is probably the key factor, and Brad's firm did an exceptional job of code review. Based on their experience, they knew where they might obtain some flexibility and where they wouldn't, and if a code - which describes a minimum, after all - wasn't adequate for the quality we wanted and could be modified, Brad said so.
Perkins: There was also a pretty high level of sophistication brought by the community to the planning process, much more so than I have found in some other places.
Could you describe how the planning process was accomplished?
Perkins: I don't think I've ever seen a more successful joint effort between a facility owner, the building committee, the contractor and the design team. As an example, even after the final working drawings were completed, it was decided to scrutinize these in detail one more time and try to take another 10% out of the projected cost. This is usually almost impossible to do at this stage. As it turned out, though, we ended up saving $1.3 million, with no real sacrifice in quality of care or of the design itself.
Young: The key factor was that we had assembled a building committee of experts. We had plumbing contractors, steel fabricators, electrical contractors, a painter, a paver, a plumbing supplier, an electrical wholesale supplier, kitchen equipment supplier - the list goes on and on. These people did this at a tremendous sacrifice; because they served on the building committee, they couldn't bid on the job. Instead, they stepped forward to provide the expertise necessary to design and engineer the facility, with the goal being the highest-quality home to serve our elderly.
We looked at the drawings and we picked things apart in detail, bit-by-bit, trying to make changes that would save money but not affect the quality of care. For example, we changed the roofing system and specified a change in mechanical systems; the change in mechanical systems not only saved money, but ended up providing more control for our residents.
Perkins: There were probably 150 items we went through, all the way down to different hardware to affix handrails to walls; that change alone saved a few thousand dollars.
Young: Still, you can be as detailed as you want, and you won't get anywhere unless everyone is willing to work together to get it done. There has to give-and-take, and you have to realize that some things will be changed, and some won't. But Brad is right - we saved $13 million a thousand dollars at a time.
Perkins: In a process that took about 8 weeks.
Young: It seemed like a lifetime.
What are some other highlights you remember of the planning collaboration?
Young: Ed Vinocur suggested that we build a mock room so we could actually see how everything came together. It was tremendously helpful. We could see how the furniture fit, what the problems were, what could be changed and what couldn't. Several of us also spent a day at Brad's office in New York sitting at a CAD (computer assisted design) computer and seeing how wheelchairs would actually negotiate the rooms we were creating.
Vinocur: We also bought samples of everything so residents and staff could try them. We didn't want to order furniture, for example, until our residents had actually had a chance to evaluate it for ease of sitting, drawer function and the like. We did this on the grounds that residents "take up ownership" of a facility, and they should feel that way. It helps in the transition to a new building.
Also, while drawings were being prepared, we did a great deal of planning on how the building would function inside. There were little things, such as where wall outlets should be located and how the furniture should be laid out, that we addressed early on. In general, we created a profile showing how the building would operate most efficiently before any of the hard walls went up.
Young: I mentioned before the give-and-take process. I remember being questioned by the chairpersons of the interior sub-committee and having a lengthy conversation over the size of the floor tiles. I wanted to save a little money, they wanted esthetics - and esthetics won. It was clearly a matter of listening to their perspective and understanding the overall look and quality of the facility. We balanced cost, quality and esthetics. The overall approach was that we didn't look at this as a building, but as a set of components that would be put together to make a building. I think that was why the overall project turned out so well.
What about the construction process? Were there any surprises?
Perkins: Any construction job has surprises, but this didn't have those "life-threatening" crises that tend to come up.
Young: That's true, there may have been a delivery of defective material that we turned down or similar problems, but there was nothing major.
I attribute this to a couple of things. We had owner representation on the site on a daily basis. Very, very careful notes were taken and meetings were held regularly. We had a good contractor, Snavely Construction, who was very paperwork-oriented; this can get a little cumbersome, it's true, but it results in a lot more communication among everyone involved and decisions getting made.
Another factor was the tone set by Ed Vinocur. He emphasized cooperation, but he also let it be known that he wasn't going to put up with a lot of nonsense, that he expected people to deliver what they promised, and that he would settle for nothing less.
It was a very professional atmosphere, and that's what you have to have. A lot of owners and administrators, I'm afraid, don't understand this. They take a look at the bid, ask what's the number, and say, "Let's go." Ed took the attitude that you hire professionals, you listen to what they have to say, and you make your decisions.
Any final reflections on this process?
Perkins: Everyone knew that, if we did this right, it would be a model facility that everyone would come to see. And everyone got into the spirit of this. It became one of those projects that people, wanted to be associated with, and took great pride in doing so.
Vinocur: Altogether, I would say it was a labor of love for everyone involved.
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|Title Annotation:||interview with Montefiore Home administrator Edward Vinocur, architect Brad Perkins, and building committee chairman Darrell Young|
|Author:||Peck, Richard L.|
|Date:||May 1, 1992|
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